Mental Health and Substance Use Among Patients in a North Carolina HIV Clinic

Discussion

This study examined mental health and substance use and their association with ARV medication adherence among patients in a large HIV clinic. Rates of mental health distress and substance use were high in this sample of HIV-infected patients. Compared to a national study that administered the same depression screening instrument, indications of depression were over 1.5 times higher in our sample than among the general population (12.2% versus 7.2%) [21]. A previous study conducted a decade earlier in this setting found rates of mental illness to be 60%, but that study had a much broader definition of mental illness and did not provide information about specific types of symptoms [22]. In our sample, there were no racial differences in current rates of depression. However, white patients in our sample reported much higher rates of ever having been diagnosed with depression and of ever having been prescribed psychiatric medications. These findings are consistent with the wider literature on depression. A large national prevalence study found higher lifetime rates of depression among non-Hispanic whites than among African Americans, but it found no racial differences in diagnoses of depression in the past year [23]. Differences between current depression symptomology and engagement with mental health treatment may reflect disparities in access to these services [24].

A majority of our sample reported current alcohol use, with nearly one-fifth (19%) having indications of problematic drinking; about 1 in 10 patients (8.2%) had indications of problematic drug use. A study conducted a decade ago in this setting reported that 32% of patients were abusing substances, but it is difficult to compare these results with our findings because the previous study collapsed drug and alcohol abuse into a single category [22]. Drug use in our sample is slightly lower than national prevalence rates for patients with HIV, with one national study finding that 12% of HIV-infected adults screened positive for drug dependence within the past year [5]. In contrast, while national prevalence studies suggest that 8–11% of HIV-infected individuals are heavy or hazardous drinkers [6, 25], 19% of patients in our sample had indications of problematic drinking. This high level of alcohol use may be a reflection of contextual factors that contribute to the prevalence of HIV in this region, including high levels of HIV-related stigma [26, 27]. Substance use may be a means of coping with stress related to living with HIV [28, 29].

The rate of cigarette smoking was also much higher in our sample compared to the national rate (31% versus 19%) [30], although other studies of HIV-positive individuals have found smoking rates ranging between 50% and 70% [31]. Smoking rates were particularly elevated among women, who reported smoking at a rate nearly double national estimates (30% versus 17%). In our sample, minority individuals were significantly more likely to report smoking than whites. This difference is notable given that national data suggest that the smoking rate for minorities is comparable to or lower than the rate for whites (19% for non-Hispanic blacks, 13% for Hispanics, and 21% for whites)

The high prevalence of smoking in our sample is troubling because there is evidence that HIV-infected individuals are more vulnerable to the harmful effects of tobacco. Specifically, a large, multisite study of veterans found that smoking conferred a significantly higher risk of mortality among HIV-positive individuals compared to demographically matched HIV-negative individuals [32]. Although research is needed to understand the mechanisms by which smoking increases mortality in this population, there is some evidence that tobacco may reduce the effectiveness of highly active antiretroviral therapy (HAART) [33]. This underscores the importance of targeting smoking cessation efforts in this population.

About one-quarter of our sample reported suboptimal adherence to ARV medications. A meta-analysis of studies across a variety of settings has shown that nearly half of HIV patients have suboptimal adherence [34]. Higher adherence in our sample may be due to selection bias. Approximately 500 patients were enrolled in the clinic but did not fill out the questionnaire, either because they refused to participate or because they did not attend any clinical appointments over the 18-month period of data collection. Another 281 patients completed portions of the questionnaire but skipped questions related to adherence. It is possible that the nearly 800 patients who did not disclose adherence habits were significantly less adherent, which would bias our findings.

Disclosure of suboptimal adherence behaviors may have been further compromised by the fact that data reported in this study were collected through a health behavior questionnaire administered as part of routine clinical care. Patients completed the questionnaire knowing that their responses would be reviewed by their health care provider. This may have introduced social desirability bias and created barriers to full disclosure of highly personal and potentially stigmatizing health behaviors. However, it is notable that a significant number of patients voluntarily reported sensitive information, suggesting a willingness of patients to engage in conversations with their health care providers regarding these behaviors. This lends strength to the recommendation that HIV care providers routinely assess mental health, substance use, and medication adherence as a part of clinical care [35-37]. Routine screening for these issues allows providers to address barriers to care, make appropriate referrals, and provide more comprehensive support to their patients.

In our sample, suboptimal adherence to ARV therapy was significantly correlated with depression symptoms. This finding, which is consistent with previous research documenting a robust relationship between depression and poor adherence to HIV medications [12, 13], provides strong evidence to suggest that addressing depression may improve both adherence to HIV treatment and subsequent HIV-related clinical outcomes. Moreover, treating depression may also reduce HIV risk transmission behaviors, including sexual risk taking and substance abuse, thus serving as an effective secondary HIV prevention strategy [38].

Younger patients and patients of minority race/ethnicity were also more likely to report suboptimal medication adherence. This may reflect less engagement with the health care system, which could be caused by a variety of factors. Younger patients may be unfamiliar with the health care system due to a shorter history of engagement, and/or they may lack the financial stability to attend appointments regularly [39]. Among minority patients, feelings of discrimination may lead to distrust and disengagement [40], and economic or social circumstances, including HIV stigma, may limit access to care and consistent use of medications [41, 42].

Suboptimal adherence among minority individuals may also be related to social and contextual factors such as poverty and lack of consistent access to care. Poverty can exacerbate the problem directly, though lack of insurance and affordable care, as well as indirectly, particularly for minorities, through its association with depression and discrimination [43]. Of individuals in this clinic, for example, only approximately one-fourth have private insurance. This is crucial to consider because the presence of unmet basic needs, such as food and shelter, is known to have the greatest effect on HIV disease progression, over and above medication adherence [44]. Given the high burden of HIV infection in minority communities in the South [1], there is an urgent need to better understand cultural and structural barriers to engagement with HIV care and to provide targeted outreach and services to appropriately engage these high-risk populations and retain them in care.

Findings from our study also suggest a need to increase access to behavioral health services. Standard pharmacological and psychotherapy interventions have been shown to be effective among HIV-infected populations [45-47], and thus greater integration of these services into HIV clinics has the potential to significantly improve the identification and management of mental illness. There is evidence to support the successful integration of depression or substance use treatment into nonpsychiatric clinical settings [48-50], suggesting that it would be feasible to co-locate these services in HIV clinics [51]. Additionally, given the low socioeconomic status of many patients in the clinic, it may also be important to consider environmental barriers that prevent engagement with care. Antidepressants and psychotherapy interventions have been shown to effectively reduce depression among minority, low-income populations when coupled with educational outreach, child care, and transportation [52].

This study has several limitations, in addition to the challenge noted above regarding possible social desirability bias. First, although the health behavior questionnaire was given to all patients, some opted not to fill out the form. Generalizability of our findings may be limited because we do not have information regarding patients who chose not to fill out the form. Non–English-speaking patients may not have been able to complete the form, which may be a reason for the low representation of Latino patients in our sample. Second, we did not have enough power to look at interactions between demographic groups. Future research would benefit from comparing demographic subgroups (eg, minority women versus minority men) to determine whether there are significant differences with regards to retention in care, as such information could be used to inform specialized outreach efforts. Third, use of each patient's most recently completed questionnaire may have biased our results, as it is possible that patients had respondent fatigue and may not have completed the form fully or accurately. Fourth, assessment of medication adherence is based on a single self-reported response, which may be compromised by social desirability bias or difficulty remembering the exact time that a dose of ARV medication was last missed. Future research would benefit from a more comprehensive assessment of treatment engagement, beyond medication adherence; criteria could include consistently staying in care for an extended period of time [53] or viral suppression. Fifth, the relationship between suboptimal adherence and minorities may be confounded by factors that were not measured in the study, such as social support or HIV disclosure. Sixth, the clinic questionnaire was entered into a separate research database that is not linked to patients' medical records. As a result, we were not able to examine associations with clinical outcomes such as CD4 count or viral load. Finally, diagnoses of mental illnesses were measured by patient self-report; we did not have the resources to confirm past psychiatric diagnoses via medical record review or to conduct clinical assessments to confirm current diagnoses.

In summary, our findings suggest that addressing depression may be a key to improving ARV medication adherence among HIV patients in North Carolina. Providing comprehensive care that addresses mental health and substance use in the HIV clinic setting may lead to improved clinical outcomes. In addition, while access to comprehensive care is necessary, patients must also be motivated to participate in care. In the clinic setting, medical and other providers can boost patient motivation through routine screening; brief interventions with patients in the way they talk about alcohol and substance use; and referral to mental health and substance use services, which are ideally integrated into the HIV clinical care setting [54, 55]. In particular, minority patients, as well as younger patients, may be at higher risk for poor adherence, and thus would especially benefit from increased efforts to improve engagement and adherence.